Observation

kburow5446@gmail.com

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our providers admit to observation but fails to meet the documentation requirements in their H&P note, meaning he only has the following:

Expanded problem focused history
Comprehensive Exam
Comprehensive MDM

He isn't meeting the 3 out of 3 needed for the lowest level admit to observation 99218. What are our options at that point? Billing 99499 or not billing anything at all? If I don't bill the admission code for this reason....can we bill our discharge code the following day?
 
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Meet or exceed ≥

HI
The evaluation and management services guidelines under "select the appropriate level of E/M services based on the following states for hospital observation all three components must "meet or exceed' the requirements for a code level. That means that the level of the three components must be at least equal to the lowest level documented.

If the documentation does not meet the lowest level required you can level at a different category E&M. The choice is contingent on the POS, is this in the ER? Does an ER visit fit? Is this a new patient to the Physician? A 99202 might be fitting?

Is this patient known to the Physician? An established outpatient code is based on 2 of 3 meeting or exceeding rather than all three meeting or exceeding, so under that rule, you have two comprehensive levels and the code would be 99214 or 99215.

You will want to use an established CPT code that fits the POS and documentation requirement before reaching for an unlisted code.

I hope this helps
 

thomas7331

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If the documentation does not meet the lowest level required you can level at a different category E&M.

I disagree with this statement. If you're provider is the admitting physician, it's not appropriate to select a different code category. Other outpatient E&M service codes are approved for use by CMS for consulting providers now that the consultation codes are not accepted, but that would not apply in your situation it this is for the admitting provider. I believe you're suggestion of the unlisted code would be the most appropriate in this case.
 
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Inpatient vs outpatient

Observation is outpatient, the code category for inpatient is 99221-99223. Until the patient is admitted to inpatient the code range is variable to outpatient codes
 

thomas7331

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After reviewing this a little more, I will backpedal a bit on my previous response - CMS guidelines state that only the admitting physician may bill the observation codes, and don't specifically prohibit them from billing other outpatient codes, so I do think this would be compliant, but you might want to check specific payer guidelines. I'd be hesitant to do this routinely though because the work of admitting a patient to observation is usually significantly different than that of a lower level outpatient visit and the providers may just need to be educated on the documentation requirements so that they are getting the correct code for the work they're actually doing. Sorry if I gave incorrect guidance.
 
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